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Medication management in the NSW personal injury schemes: Better practice guide

Introduction

Some medications used to treat injuries sustained at work or on the road have the potential for negative health outcomes, dependence and accidental overdose. This guidance aims to minimise the potential harms associated with the use of medications to support optimal health outcomes for people in the NSW workers compensation (WC) and compulsory third party (CTP) schemes. The guidance includes recommendations for:

  • high risk medications that should be monitored
  • the application of the Pharmaceutical Benefits Scheme (PBS)
  • indications and use of a medication review
  • standardised invoicing requirements for pharmacies.

Medication prescription and supply

Medications in the NSW personal injury schemes:

  • must be for the treatment of the person’s compensable injury
  • must be prescribed by a legally qualified medical practitioner or dentist registered with Australian Health Practitioner Regulation Agency (AHPRA) under the Health Practitioner Regulation National Law
  • must be supplied by a registered pharmacist
  • should be prescribed and supplied through the PBS system unless the medication is not available on the PBS or there are extenuating circumstances.

1.   High risk medications

These prescription medications have been identified as high risk based on current research evidence. They have the potential for negative health outcomes, dependence and accidental overdose and are the focus of the guidance:

  • opioids
  • medication-assisted treatment of opioid dependency (MATOD)
  • injectable narcotics
  • benzodiazepines and z drugs
  • medicinal cannabis.

All of these high risk medications are either prescription only (schedule 4), or drugs of addiction (schedule 8). Further information is included in Appendix 1.

Monitoring high risk medication

In line with best practice, it is recommended that insurers monitor the use of high risk medications in the NSW personal injury schemes and the use of medication reviews.

MedicationMonitoring recommendations

Opioids (pain)

  • PBS opioids prescribed under the PBS
  • PBS opioids prescribed privately
  • Non-PBS opioids (not on PBS and can only be prescribed privately)
  • Injectable narcotics
  • Opiate replacement therapy / Medication assisted treatment of opioid dependence (MATOD).

Benzodiazepines and z drugs (sleep and anxiety)


  • PBS benzodiazepines prescribed under the PBS
  • PBS benzodiazepines prescribed privately
  • Non-PBS private benzodiazepines (not on PBS and can only be prescribed privately)
  • Non-PBS Z drugs
Emerging medications
  • Medicinal cannabis
All other medications
  • Prescription
  • Over the counter

2.   Pharmaceutical benefits scheme (PBS)

The PBS supports the safe and quality use of medications and provides a built-in safety mechanism when dealing with high risk medications.

People receiving their medication related to either a WC or CTP claim who hold a Medicare card are entitled to access the PBS. The person must present their Medicare card and any concession/entitlement card to the pharmacist.

The prescription and supply of medications in the NSW personal injury schemes should be provided under the PBS where clinically appropriate and available.

Private (non-PBS) prescriptions

A private prescription can be written for non-PBS listed medications or PBS medications that the prescriber chooses to prescribe privately.

A prescriber may provide a private prescription when:

  • a medication is not available on the PBS
  • a medication is available on the PBS, but the patient does not meet the criteria for PBS prescribing
  • the quantity of medication or number of repeats being prescribed for a PBS medication falls outside the PBS prescribing criteria.

When any of the high risk medications, and in particular drugs of addiction (Schedule 8) are prescribed privately, it is recommended in the NSW personal injury schemes that:

  • the prescriber provides written clinical rationale that explains why they are prescribing:
    • a medication that is not available through the PBS or
    • a medication that is available through the PBS through a private prescription
  • the insurer may request a medication review to assess the clinical appropriateness of the private prescription
  • the insurer should pay a reasonable private rate.

Note: In the workers compensation system, high risk medications prescribed using a private prescription within the 30 day pre-approval period do not require clinical rationale.

3.   Medication review

Harms and risks can occur with ongoing use of high risk medications. A medication review can be requested by an insurer to provide an independent assessment of the overall medication prescribed.

It is conducted by a consultant pharmacist or medical advisor with the person and their doctor.

The review should result in a medication plan informed by evidence and clinical best practice guidelines.

A medication review is indicated when there is:

  • a repeat prescription for high risk medications
  • multiple opioid medications
  • a combination of high risk medications (eg opioids, benzodiazepines, sleep medications and antidepressants)
  • multiple prescribers (this excludes multiple practitioners within the same clinic prescribing high risk medications that are in accordance with the authority details for that medication)
  • multiple pharmacies supplying the high risk medications
  • injectable narcotics or medicinal cannabis prescribed
  • high risk medications used for over 2 weeks
  • high risk medications supplied in doses that exceed the manufacturer’s recommended maximum therapeutic dose
  • a transition to the GP following discharge from hospital (eg post surgery or if discharged with high risk medications)
  • comorbidities such as psychiatric disorders, cardiovascular disease, respiratory disease, sleep apnoea
  • history of drug dependence or addiction
  • a risk of self-harm
  • concern about misuse of medications (injecting, supplying to others).

Following a medication review, a practitioner suspected of overprescribing high risk medications should be referred to the relevant professional Council. SIRA should be advised of that notification with the reasons for the complaint.

4.   Standardised pharmacy invoicing

Standardised invoicing will enable insurers to see the essential information about the person’s injury related medications. It will facilitate data collection and will enable preventative and proactive management of high risk medications.

Direct billing accounts

Direct billing accounts from a registered pharmacy should provide the insurer with the following information:

  • a dispensary computer generated tax invoice for PBS and private (non-PBS) medications supplied for treatment of the compensable injury
  • the statement of account for over the counter and equipment items supplied to the person for treatment of their compensable injury.

Where the item type is not clearly identifiable on the invoice or statement, this may be handwritten:

  • OTC - over the counter
  • PBS – Pharmaceutical Benefits Scheme
  • PRIV - private (non-PBS) medication.

Invoice and statements

Invoice and statements should contain the following information.

Pharmacy details

Person’s details

Medication details

  • Pharmacy name and street address
  • Dispensing pharmacist’s name
  • ABN
  • Invoice number and date
  • Total amount charged
  • Family name and given name(s)
  • Address
  • Claim number (or date of birth   and date of injury).
  • Date of service (date dispensed)
  • PBS item code (for PBS dispensed medications)
  • A copy of the original script for medications that are available on the PBS but are dispensed privately (non-PBS), and a copy of the repeat prescription where applicable
  • Full description of the medication (including script number, brand name, form)
  • Quantity of medication dispensed
  • Strength of the medication   dispensed
  • Prescriber name/address/prescriber number
  • Amount charged per item

Reimbursements

To claim a reimbursement, the person should request that the pharmacy provide them with:

  • a dispensary computer generated tax receipt for PBS and private (non-PBS) medications supplied for treatment of their compensable injury
  • a dispensary receipt or a cash register receipt for over the counter and equipment items supplied for treatment of their compensable injury.

The insurer may request further information from the person or the pharmacy provider if the invoices or receipts (for example, a cash register receipt) have insufficient detail to identify the medication or item that was supplied to the person.

Appendix 1: High risk medications

Scheduling is a national classification system that controls how medicines and poisons are made available to the public. Medicines and poisons are classified into Schedules according to the level of regulatory control over the availability of the medicine or poison required to protect public health and safety.

Schedule 8 drugs (S8 or drugs of addiction)

Schedule 8 medications are classified as drugs of dependence according to the Drugs and Poisons Controlled Substances Act 1981. The misuse of S8 medications can lead to physical and psychological dependence and significant harm. To mitigate this risk, their supply and use are controlled and restricted.

These include opioids to treat pain and some benzodiazepines used to treat anxiety and sleep disorders.

A full table of Schedule 8 drugs is available on the NSW Health website .

Schedule 4 medications (S4)

Schedule 4 medications are prescription only medications.

These includes benzodiazepines (predominantly used to treat sleep disorders and anxiety), sleeping tablets, codeine (in combination with paracetamol or ibuprofen), and dextropropoxyphene.

Z drugs (S4)

Zolpidem and zopiclone are included under sedatives (hypnotics for the treatment of insomnia). They are considered high risk when combined with other high risk medications and are meant to be used on a short-term basis for the treatment of insomnia. They are often used on a long-term basis, referred to as 'off-label' and treatment is no longer evidence based.

Opiate replacement therapy / Medication-assisted treatment of opioid dependence (MATOD) (S8)

MATOD medications are medications prescribed by doctors to assist people addicted to opioid medications.

Injectable narcotics (S8)

Injectable narcotics are opioid medications that are injected into the body. They are the most high risk opioids due to delivery direct into the blood stream.

Medicinal cannabis (S4 or S8 depending on concentration)

Medicinal cannabis are cannabinoid-based medications used for pain management as well as for managing anxiety and sleep disorders.

References

High risk medications

Chapter 4 of this report lists 76 references that provide information on the evidence of harm from prescription medications.

Pharmaceutical Benefits Scheme (PBS)

Australian Register of Therapeutic Goods (ARTG) ARTG listed medicines

Drugs of addiction (S8)

Injectable narcotics

Medicinal Cannabis

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